Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Mat-Su Regional Medical Center

  • Physical Environment & Infection Control Rounds - OR Areas 2013

  • EC.04.01.01.14.a

  • Surveyed By:

  • Surveyed By:

PATIENT SAFETY MANAGEMENT

  • Are corridors kept clear to allow adequate space for:

  • A) Patients, visitors and staff to walk safely?

  • B) Carts, wheelchairs, equipment and beds to pass with

  • C) Are floors clear and slip-resistant finishes in place?

  • Are medication and sharps secured and locked:

  • A) Are medication rooms and anesthesia carts locked when not attended?

  • B) Are needles and syringes locked when unattended?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

FIRE SAFETY MANAGEMENT

  • Are the means of egress corridors/exit doors:

  • A) Clearly and correctly marked for EXIT, including when fire doors are closed?

  • B) Are lights in exit signs functional?

  • C) Clear of any obstructions/equipment?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are all fire extinguishers:

  • A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?

  • B) Inspection tags current? (monthly and annual)

  • C) Safety seals intact and in place?

  • D) Accessible, with three foot clearance in all directions?

  • E) Within seventy five feet in any direction in the area?

  • F) Are there CO2 fire extinguisher in place for use in operating rooms?

  • G)Is there a roll of orange masking tape in the extinguisher box? (main corridors only)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are the fire alarm pull stations:

  • A) Accessible, with three foot clearance in all directions?

  • B) In good condition, free from tampering and glass bar in place where applicable?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are combustible materials: cardboard, boxes, paper, linen, wastes)

  • A) Stored in proper containers? (32 gallons or less)

  • B) Kept to a minimum for daily use in department?

  • C) Properly labeled and identified?

  • D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inches from device)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Compressed gases and trash/linen chutes:

  • A) Are there less than 12 E-tanks (300 cu ft, oxygen) stored in the smoke compartment?

  • B) Where compressed gas storage exceeds 300 cu ft, is there a designated, protected storage room?

  • C) Full and empty O2 cylinders in storage are segregated? (Full & Empty)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Fire Building Systems, components and Safety Practices:

  • A) Are all doors free from being propped, wedged or held open in any way?

  • B) Are all doorways clear to close properly?

  • C) Do patient room doors latch when closed?

  • D) Do fire and stairwell doors latch positively and maintain closure?

  • E) Do door coordinators function properly where installed?

  • F) Are all doors physically in good condition to prevent the spread of smoke or fire?

  • G) Are rooms used as patient sleeping rooms free of deadbolt locks?

  • H) Is the area free from any evidence of smoking in the area?

  • I) Are furnishing and decorations fire-rated?

  • J) Is there at least 18 inches of clearance between storage and sprinkler heads?

  • K) Are escutcheons in place on sprinkler heads and are they clean and free of debris?

  • L) Do patient privacy curtains have at least an 18 inches mesh top?

  • M) Is the area free from portable heaters and heating devices? (No heaters in the hospital per CHS)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

SAFETY MANAGEMENT

  • Are the floors in hallways:

  • A) In good physical condition?

  • B) Clean and dry?

  • C) Free from trip/fall hazards?

  • D) Wet floor signs used properly?

  • E) Carpet free of wrinkles or tears?

  • F) Free from obstruction? ( wires/cords etc.)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are the walls:

  • A) Painted and in good physical condition? (Free of holes or water damage)

  • B) Free from exposed wiring of any kind?

  • C) Are electrical covers/plates in place and in good condition?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are ceiling tiles:

  • A) In place and in good condition?

  • B) Free of dirt, mold, dust and stains?

  • C) Free from evidence of water stains?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

INFECTION CONTROL MANAGEMENT

  • Infection Control Practices:

  • A) Are all sharps containers less than 2/3 full?

  • B) Is clean linen kept covered?

  • C) Is the clean linen physically and clearly separated from the dirty linen?

  • D) Are all medications dated and labeled?

  • E) Any outdated medication/supplies found?

  • F) Are refrigerators labeled to identify Patient,Staff and Medication use?

  • G) Are all foods dated and labeled?

  • H) Are current temperature logs in place and readily available?

  • I) Are cardboard boxes off the floor, with no corrugated shipping containers present?

  • J) Is there evidence of BLOOD BORNE PATHOGEN PRECAUTION procedures in place? (gloves, masks, gowns, separation of waste, etc.)

  • K) Is personal protective equipment readily available for use?

  • L) Are the cabinets under the sinks free from storage of clean supplies/equipment?

  • M) Are all sharps storage areas kept locked at all times?

  • N) Have all product recalls been corrected by department?

  • O) Are floors, fixtures and equipment in clean condition?

  • P) Are patient rooms and bathrooms clean and suitable for patient care?

  • Q) Are emergency showers and eye washes tested?

  • R) Are current temperature logs in place and readily available on all blanket warmers? Are temperatures within range for blanket warmers (<130) and fluid warmers (<110)?

  • S) Are carts and transport equipment free of dirt, rust and corrosion?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

HAZARDOUS MATERIAL AND WASTE MANAGEMENT

  • Hazardous chemicals used in the area:

  • A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)

  • B) Labeled correctly?

  • C) Disposed of correctly? (Are there procedures for disposal?)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • MSDS Manual in the Area:

  • A) Have the department inventory (online) been updated within the past 12 months?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Medical Waste:

  • A) Stored in properly labeled bags and containers?

  • B) Properly stored and disposed of?

  • C) Stored and segregated appropriately?

  • D) Are bio-hazardous waste bulk storage areas secured, except to essential personnel?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

MEDICAL EQUIPMENT MANAGEMENT

  • A) Are the inspection tags current with date of next inspection?

  • B) Is clean equipment identified and stored properly?

  • C) Are crash carts or carts with sharps and meds locked?

  • E) Are crash cart logs documented consistently?

  • F) Are medical equipment consumables (defib, pads, etc.) within expiration dates?

  • G) List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are current.

  • H) Are daily air removal tests (DART) performed on sterilizers and do records show compliant test results?

  • I) Are daily biological tests performed on sterilizers and do records show compliant test results?

  • J) Are sterilizer records on file for each load?

  • K) Are integrator tests on file for each flash load and do records show compliant test results?

  • L) Are PM records for sterilizers current and is equipment in good condition?

  • M) Is there a current list of scope in SPD?

  • N) Are scopes stored per policy? Clean area and 6in off the ground or in a cabinet

  • M) Are PM records for sterilizers current and is equipment in good condition?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

UTILITY MANAGEMENT

  • Are emergency power outlets:

  • A) Clearly marked by red covers and outlets?

  • B) Being used for critical equipment only?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Electrical panels and devices:

  • A) Are breakers in distribution panels labeled?

  • B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

  • C) Are all covers free from damage, securely in place?

  • D) Are waiting rooms provided with tamper-resistant outlets?

  • E) In the area free of extension cords and multi plug-in outlet strips? (Patient care area only )

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are medical gas zone and main valves:

  • A) Marked to identify the area served?

  • B) Are the valves accessible for immediate access? And not blocked?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are plumbing systems:

  • A) Autoclaves free of leaks from supply, drain or splashing?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Temperature and humidity:

  • A) Is temperature and humidity monitored in each OR and areas where anesthetic gases are administered?

  • B) Are temperatures maintained between 68 and 73 degrees?

  • C) Are relative humidity levels maintained between 35 and 60 percent?

  • D) Have appropriate actions been documented when readings are outside of parameters?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Area pressures:

  • A) Are all of the OR positive pressure to corridors?

  • B) Is the SPD clean storage positive pressure to the corridor?

  • C) Is the scope storage area positive pressure to adjoining rooms and or corridor?

  • Have appropriate actions been documented when readings are outside of parameters?

SECURITY MANAGEMENT

  • SECURITY

  • A) Are all employees wearing identification badges in plain view?

  • B) Are all computer rooms locked except to essential personnel?

  • C) Are all computers that are not in use - logged out?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

EMERGENCY MANAGEMENT

  • EOP

  • A) Is the department emergency lighting box locked?

  • B) Are the Emergency Procedures flip charts easily accessible?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

HAZARDOUS AREAS - (LS 19.3.5.4)

  • Soiled Utility Rooms and Storage Rooms >50 Square Feet (Example 5X10)

  • A) Clean, neat and orderly?

  • B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?

  • C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

  • D) Do doors to Hazardous Areas have automatic closers?

  • E) Do doors to corridors and rated rooms positively latch?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)

  • Staff Member Job Title:

  • FIRE SAFETY MANAGEMENT

  • A) What does R.A.C.E stand for? Rescue, Alarm, Confine, Extinguish or Evacuate

  • B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box

  • C) When was your last time you participate in a OR fire drill and or training. (Should be annually)

  • SAFETY MANAGEMENT

  • A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  • B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)

  • C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)

  • D) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC Safety Manual link)

  • HAZARDOUS MATERIALS & WASTE:

  • A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)

  • B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)

  • C) Can staff explain the code for a large HazMat spill? (Code Orange)

  • MEDICAL EQUIPMENT:

  • A) If a piece of medical equipment fails on a patient, you should? ( Call your supervisor, remove it from service (keep all items like disposables), place an out of serviced; slip on it, complete; submit an event report to Risk Management)

  • B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

  • C) Can staff explain emergency procedures for life-support equipment? ( Describe what they should do for various life support equipment failures).

  • UTILITIES:

  • A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? (Resp. Therapy, Charge Nurse)

  • SECURITY:

  • A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

  • B) Can staff explain their role to get help with an uncontrollable person? ( Dial 6999 & have operator call a Code Strong)

  • D) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink.)

  • E) Are security measures in place for the OR and can staff explain their role in providing security for patients?

  • EMERGENCY MANAGEMENT:

  • A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  • B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  • C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)

STAFF QUESTIONS: 2

  • Staff Member Job Title:

  • FIRE SAFETY MANAGEMENT

  • A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

  • B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box

  • C) When was your last time you participate in a OR fire drill and or training. (Should be annually)

  • SAFETY MANAGEMENT

  • A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  • B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)

  • C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)

  • D) Do you know where to find a current copy of the EOC/Safety manual online?(On the Intranet Home page. Click on the EOC Safety Manual link)

  • HAZARDOUS MATERIALS & WASTE:

  • A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)

  • B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)

  • C) Can staff explain the code for a large HazMat spill? (Code Orange)

  • MEDICAL EQUIPMENT:

  • A) If a piece of medical equipment fails on a patient, you should? Call your supervisor, remove it from service (keep all items like disposables), place an &;out of serviced; slip on it, complete; submit an event report to Risk Management

  • B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

  • C) Can staff explain emergency procedures for life-support equipment? (Describe what they should do for various life support equipment failures.)

  • UTILITIES:

  • A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? ( Resp. Therapy, Charge Nurse )

  • SECURITY:

  • A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

  • B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & have operator call a Code Strong)

  • C) Can staff explain where to go and what to do when a Code Pink is called? (Should know what exit their department is assigned to cover during a Code Pink.)

  • D) Are security measures in place for the OR and can staff explain their role in providing security for patients?

  • EMERGENCY MANAGEMENT:

  • A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  • B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  • C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)

  • Comments/Observations

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

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  • Department Director or Representative:

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  • Lead Surveyor:

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